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Precision Medicine: The Coolest Part of Medicine

QuellosOne size rarely fits all. Most medical knowledge is derived from studying groups of subjects, subjects who may be different in some way from the individual who walks into the doctor’s office. Basing medicine only on randomized controlled studies can lead to over-simplified “cookbook” medicine. A good clinician interprets study results and puts them into context, considering the whole patient and using clinical judgment to apply current scientific knowledge appropriately to the individual.

CAM practitioners claim to be providing individualized treatments. Homeopaths look up symptoms like “dreams of robbers,” “sensation of coldness in the heart,” and “chills between 9 and 11 AM” in their books, and naturopaths quiz patients in great depth about their habits and preferences; but they don’t have a plausible rationale for interpreting the information they gather. And they have not been able to demonstrate better patient outcomes from using that information.

A new concept, “precision medicine,” was recently featured in UW Medicine, the alumni magazine of my alma mater, the University of Washington School of Medicine. Precision medicine strives to provide truly individualized care based on good science. It identifies the individual variations in people that make a difference in our ability to diagnose and treat accurately. Peter Byers, MD, director of the new Center for Precision Diagnostics at the University of Washington, calls it “the coolest part of medicine.” (more…)

Posted in: Basic Science, Cancer, technology

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What’s in a name?: NCCAM tries to polish a turd

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What’s in a name? that which we call a rose
By any other name would smell as sweet;
So Romeo would, were he not Romeo call’d,
Retain that dear perfection which he owes
Without that title. Romeo, doff thy name,
And for that name which is no part of thee
Take all myself.

William Shakespeare, Romeo and Juliet, Act II, Scene 2

You can clean up a pig, put a ribbon on its tail, spray it with perfume, but it is still a pig.

You can paint a turd red, but it’s still a turd.

There’s a colloquial phrase commonly used to describe an effort to sell or promote something that is so inherently awful or at least so flawed as to be unsalvageable without either a radical rethinking or such a major overhaul that it would be impractical or impossible to do: Polishing a turd. In this, advocates of so-called “complementary and alternative medicine” (CAM) have been very successful. Mark Crislip, in his usual inimitable fashion, just reminded us why CAM is a turd that needs polishing. Unfortunately, on Friday, I learned that the National Center for Complementary and Alternative Medicine unveiled a proposal to help it be more efficient in polishing the turd that is CAM through the clever use of language, and it wants your feedback. There were lots of other things that happened over the last few days that tempted me to write about them that will likely have to appear over at my not-so-secret other blog, but this one caught my attention and held it, given that it goes to the very heart of the deceptive use of language that is at the heart of giving CAM the appearance of legitimacy. In this specific case, NCCAM wants a new name. Dr. Briggs wants to rename NCCAM the National Center for Research on Complementary and Integrative Health (NCRCI). (I have no idea why the abbreviation of the proposed new center name isn’t NCRCIH.) Here’s Dr. Briggs explaining the rationale for the proposal and urging feedback by June 6 at http://nccam.nih.gov/about/offices/od/comments. I urge you to watch the whole video, or at least read the transcript:

Thus does Dr. Briggs propose polishing the turd that is NCCAM.
(more…)

Posted in: Clinical Trials, Medical Academia, Politics and Regulation

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More Dialogs

There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. JAMA

Just just because there are flaws in aircraft design that doesn’t mean flying carpets exist. Ben Goldacre

Wiser heads than I have commented on “Invitation to a Dialogue: Alternative Therapies” in The New York Times. So why add my two cents? Partly because The New York Times wanted brief responses and I don’t do brief. Partly because I write for me; nothing focuses the mind like putting electrons to LCD, except, perhaps, a hanging. Partly we do need a dialog, just not of the kind suggested by the writer. And partly, life has been so busy of late I needed a topic that required no research. (more…)

Posted in: Basic Science, Clinical Trials, Critical Thinking, Science and Medicine

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Legislative Alchemy 2014 (so far)

Legislative Alchemy is the process by which credulous state legislators turn practitioners of pseudoscience into state-licensed health care professionals. In addition to unleashing quackery such as homeopathy, colonic irrigation, moxibustion, reiki, cranial sacral therapy and the detection and correction of subluxations on the public, these practice acts typically give chiropractors, naturopaths and acupuncturists the freedom of being governed by their own regulatory boards, to which the practitioners themselves are appointed. The boards, in turn, write the administrative rules governing practitioners and handle public complaints about their services. In the worst cases, legislatures simply hand out the privilege of practicing medicine to pretty much anyone.

legislative-alchemy-image

State practice acts also establish the education and training standards for practitioners by requiring graduation from their accredited schools. Here the federal government lends a hand, by turning accreditation over to private agencies run by the practitioners themselves. The federal government also supports the schools by giving them taxpayer-funded student loans and research money. (more…)

Posted in: Acupuncture, Chiropractic, Homeopathy, Legal, Naturopathy, Politics and Regulation, Traditional Chinese Medicine

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Dialogue on “Alternative Therapies”

A recent opinion piece in The New York Times is an invitation to a dialogue on so-called alternative therapies, written by James Gordon. Gordon directs the Center for Mind-Body Medicine and was chairman of the White House Commission on Complementary and Alternative Medicine Policy appointed by President Bill Clinton. The piece, unfortunately, represents many of the common misconceptions about mainstream medicine and CAM (complementary and alternative medicine).

He begins:

Even more distressing, the Affordable Care Act will likely reinforce current practice, which dictates surgical and pharmacological interventions that can be expensive, inappropriate, burdened by side effects and, often, ineffective.

His piece is doomed right from the start. Current practice does not “dictate” drugs and surgery, no matter how often CAM proponents claim that it does. This is simply a straw man designed by CAM advocates to create a niche for their brand. Mainstream medicine uses treatments that are backed by sufficient plausibility and evidence, regardless of modality. At least, this is what mainstream medicine strives for. We acknowledge the implementation is imperfect, and improving the standard is part of what we strive for at SBM. (more…)

Posted in: Science and Medicine

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Gary Taubes and the Cause of Obesity

Gary Taubes has written two books explaining why people get fat and why a low-carb diet is the solution to preventing and treating obesity. He didn’t like what I had to say about his books on this blog back in 2011. I was not the only one to criticize. Another reviewer accused him of “abandon[ing] journalistic and scientific integrity in place of observational data, straw men and logical fallacy.” He says he agrees with Taubes’ premises but that his “arguments made me cringe,” and he goes into considerable detail to explain why. His analysis is worth reading.

photo by Fj.toloza992 [CC-BY-SA-3.0], via Wikimedia Commons]

photo by Fj.toloza992 [via Wikimedia Commons]

Rather than engaging in the Comments section, Taubes complained to me in a somewhat offensive personal e-mail, saying I had failed to understand what he wrote. Recently he e-mailed me again, condescendingly suggesting that I might understand his arguments better if I read an article he wrote last year for the British Medical Journal. I read it, and confirmed that I had understood perfectly well the first time around and that it was Gary Taubes who didn’t understand my criticisms. I pointed out some omissions and inconsistencies, but my major criticisms boiled down to two:

  1. The clinical evidence isn’t yet sufficient to convincingly prove his thesis. (He himself admitted this.)
  2. He strongly recommended that everyone adopt a low-carb diet, essentially insisting that we act on insufficient evidence. And this was after he had devoted whole chapters of his books to demonizing the low-fat diet advocates for doing exactly that: acting on insufficient evidence.

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Posted in: Nutrition

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A formal request for retraction of a Cancer article

I am formally requesting that Cancer retract an article claiming that psychotherapy delays recurrence and extends survival time for breast cancer patients. Regardless of whether I succeed in getting a retraction, I hope I will prompt other efforts to retract such articles. My letter appears later in this post.

In seeking retraction, I cite the standards of the Committee on Publication Ethics (COPE) for retraction. Claims in the article are not borne out in simple analyses that were not provided in the article, but should have been. The authors instead took refuge in inappropriate multivariate analyses that have a high likelihood of being spurious and of capitalizing on chance.

The article exemplifies a much larger problem. Claims about innovative cancer treatments are often unsubstantiated, hyped, lacking in a plausible mechanism, or are simply voodoo science. We don’t have to go to dubious websites to find evidence of this. All we have to do is search the peer-reviewed literature with Google Scholar or PubMed. Try looking up therapeutic touch (TT).

mind-over-body

I uncovered unsubstantiated claims and implausible mechanisms that persisted after peer review in another blog post about the respected, high journal-impact-factor (JIF = 18.03) Journal of Clinical Oncology. We obviously cannot depend on the peer review processes to filter out this misinformation. The Science-Based Medicine blog provides tools and cultivates skepticism not only in laypersons, but in professionals, including, hopefully, reviewers who seem to have deficiencies in both. However, we need to be alert to opportunities not just to educate, but to directly challenge and remove bad science from the literature. (more…)

Posted in: Cancer, Clinical Trials, Neuroscience/Mental Health

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Separating Fact from Fiction in the Not-So-Normal Newborn Nursery: Newborn Jaundice

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Photo by Mike Blyth

By far the most common medical problem in newborn infants is jaundice, typically appreciated as a yellowish discoloration of the skin caused by increased blood levels of a pigment called bilirubin. In my role as a newborn hospitalist, I manage jaundice every day. If I am not treating jaundice, in every single baby I see I am at least determining the risk of the child developing jaundice severe enough to require treatment. I then use that assessment to help guide my recommendations on when the infant should follow up with their primary care pediatrician after discharge home.

Fortunately for the millions of infants who develop jaundice every year, in the vast majority it is a self-limited process and often considered to be just a normal part of the first few days of life. But in a significant minority of them, careful management is required in order to prevent complications. Some infants need treatment to prevent neurological symptoms from developing, and to reverse them when they do occur. And in a very small percentage of babies who develop severe jaundice, permanent brain damage and even death can occur.

Because newborn jaundice tends to resolve without any intervention, and complications are now uncommon, it isn’t surprising that a variety of myths and superstitions have arisen that involve preventing or curing the condition. And naturally there are practitioners of unproven alternative medical modalities that can be found claiming to be able to manage it as well. As expected, if you’ve spent any time reading Science-Based Medicine or researching the nonsensical claims of chiropractors, homeopaths and their ilk, their understanding is limited and their recommendations potentially dangerous.

But first a crash course on newborn jaundice. (more…)

Posted in: Science and Medicine

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We’re a drug-taking, supplement-taking nation. So how do we do so safely?

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Do you take a vitamin or dietary supplement? It’s increasingly likely that you do, as over half of all American adults took some sort of supplement over the past 30 days. Now there’s evidence to suggest that about one-third of all Americans are taking supplements and prescription drug at the same time, which is renewing questions about risks and benefits. The same study reveals that combining supplements and prescription drugs is more common among those with certain medical conditions, compared to those without.

Many of us supplement in the absence of evidence of benefit, or even medical need. For example, there is little persuasive evidence to suggest that routine supplementation with products like multivitamins is necessary. There are exceptions of course: Those potentially becoming pregnant, those on dietary restrictions (e.g., vegans), and those with demonstrable medical need are among the cases where there is a clear benefit to vitamin supplementation, for example. The majority of us take supplements, like multivitamins, for “insurance” rather than because we have a deficiency or medical need. The evidence for non-vitamin supplements, like herbal products, is just as questionable as it is for vitamins, with few products showing meaningful health benefits. Ultimately decisions about supplements come down to evaluations of risk and benefits. Since I started working as a pharmacist, I’ve always cautioned consumers about the quality concerns and efficacy with herbal products and supplements, and the resultant risks that make me very hesitant to suggest their routine use – especially when they’re combined with prescription drugs. Yet the evidence suggests that it’s occurring – with increasing frequency. (more…)

Posted in: Herbs & Supplements, Pharmaceuticals

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CureCrowd – Crowdsourcing Science

curecrowd-HAA new website came to my attention that promises to “Discover what truly works.” The idea is to essentially crowdsource anecdotal reports about what treatments work for specific conditions.

This is an interesting idea, that can harness the power of information flow over the internet to do what is essentially an observational, uncontrolled, and unscientific study about treatment effects. At its best, this type of information would consist of what we call a pragmatic study – an open-label study of the real-world application of specific treatments.

Pragmatic studies have their place – they add information about the practical applicability of various treatments. Pragmatic studies, however, are not efficacy trials – they cannot and should not be used to make efficacy claims. It has recently come into vogue for proponents of various CAM treatments to rely on pragmatic studies to make efficacy claims, when actual efficacy trials have failed to show effectiveness. (more…)

Posted in: Clinical Trials, Computers & Internet

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